I walked into the ER today and spent an hour shooting the breeze with my fellow student. Slow night. Then I got handed two charts in a row with the same chief complaint: knee pain. I need, O Best Beloved, to review my orthopaedic tests. I did my best at the Lachman's and the anterior drawer tests, realized that it didn't matter whether a patient met the Ottawa Knee Rules or not, they were getting X-rayed, and discovered one soft tissue injury and one soft tissue injury. Football at twelve is as bad as heavy lifting at fifty. Staff backed me up and told the twelve-year-old that if he wanted to play next year he was out for the season. He cried.
More knee pain as the night progressed, more interesting this time. Depressed tibial plateau fracture with fibular head comminuted fracture (are you reading this, Mom? She's a mid-fifties lady who fell off her bike and twisted her knee; she'll probably need surgery to repair it), patient is guarding; no joint laxity. It culminated in ankle and leg pain in a darling two-year-old who fell off the slide and broke her leg (toddler fracture, see the orthopaedist in the morning, splint it for tonight).
I saw a couple of lacerations, arm and leg, and was complimented on my tricky stitching (diabetic, skin flap, lower extremity edema - this is a woman, O Best Beloved, who literally leaked fluid instead of bleeding with each pass of the needle) and on my easy stitching (eight-year-old, fell and lacerated his wrist, three people to pin him down for marcaine before I sutured). If I can do one thing, O Best Beloved, it is suture a laceration in the ED.
Lots of simple infections, urinary, sinus, chest colds, asthma and the like. One woman whose car had been hit by an out-of-control spinning road hog and was now having cramping (10 weeks pregnant, fetal heart tones strong, wait it out). I managed to avoid most of the chest pain and chronic complaints except for the man whom I correctly diagnosed with new-onset CHF requiring admission. But the highlight of the night, O Best Beloved, was the bug.
I pulled the chart out of the rack and read it. Chief complaint: bug in ear. Data: Patient states a bug crawled into his ear last night. Some pain last night, none today. I went to see him. He was a lanky black teenager. "Are you sure there's a bug in your ear?" Yes, he assured me, I can feel it. I got out the otoscope and put on the big tip. I looked in his ear. There was a bug in his ear. It was a tiny thing, no more than a quarter of an inch, but it was crawling around in there, next to his eardrum, waving its antennae at me as if in greeting, and I almost dropped the otoscope.
Mother and teen laughed with me as I explained that I didn't quite know what we were going to do as I'd never seen anyone with a real bug in his ear before, and I would have to ask my staff if there was a procedure for removing insects.
Staff laughed at me. "Big bug or little bug?" Little bug. Still crawling. "Drown it with a few drops of lidocaine and then take it out with tweezers." No, I mean really little bug. He came and looked. "Oh, we'll just irrigate it out."
And that, O Best Beloved, is what the nurses did, after much discussion over who would be doing the irrigating. It washed out after a few syringes of warm saline, and we examined it in the tray, now swimming. Tiny bug. Everyone had to see. "Maybe I should irrigate a bit more," nursing suggested. "What if it laid eggs?" Irrigation was performed to remove potential eggs. All was at peace. I don't know what happened to the bug (a little brown flat thing with long antennae, not an earwig or a roach) then - staff insisted I should take it outside and set it free, but the nurses had made it disappear before I could. The boy went home, swearing he would sleep with earplugs from now on.
1/2 cm insect successfully irrigated out with NS. Patient tolerated procedure well. Discharge in stable condition.
Sleep well, O Best Beloved.